A retrospective 30-year follow-up study of former Swedish-elite male athletes in power sports with a past anabolic androgenic steroids use: a focus on mental health

The results from this study of former male-elite athletes in sport disciplines, where increased muscle strength has a marked influence on performance, showed that at least 20% admitted AAS-use during their active sport career. The study indicates that the former AAS-users had a higher frequency of lifetime prevalence of seeking professional expertise for several mental problems. Furthermore, former AAS-users more often had used illicit drugs. Former AAS-users were significantly older when they started training in their sport discipline in which they had been most successful and they also spent more hours per week training. Furthermore, if the former AAS-using athletes used AAS for a longer time than 2 years, they had more often sought professional expertise for anxiety, irritation and anger and they had also more often a combined use of alcohol and illicit drugs together with AAS. These high-consumers of AAS reported having experienced more side effects of AAS, compared with those athletes having used AAS no longer than 2 years. A former use of AAS does not seem to have a negative long-term effect on either present substance abuse and present sport activity or on whether they presently lived in a relationship or not.

The present results can be compared with previous results regarding lifetime prevalence of AAS-use among elite athletes active in the 60s and 70s. For example, in 1972, it was estimated that one-third of the Swedish-elite track and field athletes used AAS.

The present study is, however, based on a larger number of athletes and in four power sports. In the same year’s Olympic Games, 68% of the participants in the track and field events reported prior steroid abuse. Shortly thereafter, in 1975, the International Olympic Committee (IOC) added AAS compounds to their list of prohibited substances.

Nevertheless, in the Winter Games of 1992, a query reported that about 40% of the respondents estimated that more than 10% of the participants abused AAS in their respective sport discipline.15 Statistics published by the IOC show that the percentage of athletes testing positive for AAS has decreased since the mid-1980s.16 After the introduction of drug control in sport, the frequency of doping tests worldwide has exceeded 200 000 annually, with approximately 1–2% being reported positive by IOC accredited laboratories. The majority of the positive tests have shown the presence of AAS, although AAS comprise only 15% of all drugs banned by the IOC.

The former elite athletes admitting AAS-use were significantly younger compared with the non-users. This age difference might explain why the former AAS-users are, to a higher degree, in their present employment. However, this difference disappeared when the old-age pensioners, that is, above 65 years of age, were excluded from the analysis.

Former AAS-users were significantly older when they started training in their specific sport discipline and they also spent more hours per week training. There is no obvious explanation to this later training start. The observed time spent on training among the AAS-users is reasonably explained by the known effect of AAS to make its users better tolerate hard training, ‘train throw pain’ and getting a quicker recovery, giving in summary a quantitatively higher training volume, in turn explaining the improvement in results often achieved by AAS-use. The reasons for AAS-use are those usually encountered among athletes taking AAS, which is to achieve improved results, tolerate harder training and get a quicker recovery, as

aforementioned. However, interestingly, a major reason for AAS-use is the suspicion that the opponents use AAS to a high degree. It is also important to note that the former AAS-users more often had been offered AAS compared with the non-users indicating their near connection to groups of athletes with a generally more positive attitude to AAS-use.

The results from the present study show that former AAS-users, compared with those not having used AAS, had a significantly higher lifetime prevalence concerning seeking professional expertise for mental-health problems like depression, anxiety, melancholy, concentration deficit and worry for mental health. One major drawback with the present study is that the relation in time between seeking professional help for mental problems and the use of AAS is not known, that is, if the effect is an acute or long-term effect of an AAS-use.

Studies today do show a reliable correlation between the observed mental problems and use of AAS. If one would assume that there is a relationship, it is still difficult to know whether AAS-abuse induces psychiatric symptoms or is a consequence of psychiatric symptoms or even personality disorders.

Results from some clinical studies suggest that AAS-abuse may be a function of personality disorders, while other studies suggest that AAS-abuse rather paves the way for different types of psychiatric symptoms.

Preliminary results from our own study group indicate that AAS might accentuate an already existing personality structure. Another possibility is that the abuses of AAS and psychiatric symptoms, by turns, reinforce each other in a negative manner. Though it is hard to know whether the observed effect is an acute or long-term effect of AAS, the fact remains that the former elite athletes significantly more often had sought professional expertise for mental problems compared with former elite athletes who had never used AAS. In all other aspects, the two groups did not differ in any significant way that could explain the observed effect. Another limitation associated with this work is that the data are solemnly based on men. Thus, the results are not necessarily applicable to women. Furthermore, the fact that the questionnaire asked for behaviours and psychiatric conditions that the athletes might have experienced a long time ago may affect the reliability of the observed results.

The present results showed no difference between the former AAS-users and non-users when comparing previous and present alcohol consumption and previous tobacco consumption.

However, the former AAS-users had more often used illicit drugs, and the non-AAS-users were presently more addicted to tobacco. The results also indicate that the former AAS-users, who used AAS for longer than 2 years, more often combined AAS with alcohol and illicit drugs compared with those who used AAS for no longer than 2 years. It is proven today that the use of AAS often correlates with the use of other substances. Whether AAS-use induces abuse of other substances or if drug abuse triggers the use of AAS is not yet clarified, although there are studies indicating that AAS-use can act as a gateway for misuse of other drugs.8 However, other studies do suggest that the concurrent use of AAS and illicit drugs is related to a general abuse liability.

In conclusion, at least 20% of male-elite athletes in four power sports active during 1960–1979 admitted former AAS-abuse. It is difficult to conclude from the present results whether the former use of AAS has long-term effects. The present results might instead mirror that the former AAS-users composed, for example, a certain personality structure prior to their AAS-use, which would be one of the causes behind the observed differences between former AAS-users and non-AAS-users. Other causes could include substance use and abuse as well as the influence of sociodemographic variables.

Either way, it is feasible to suspect that AAS and psychiatric symptoms reinforce each other in a negative manner.

Additionally, it is important to note that the former AAS-users more often had been offered AAS compared with non-users.

This indicates that preventing efforts against AAS are of vital importance, both inside and outside the sporting world.

1Centre for Ethics, Law and Mental Health, University of Gothenburg and the Forensic Psychiatric Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden

2Department of Social Work, University of Gothenburg, Gothenburg, Sweden

3Department of Pediatrics, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden

4Department of Clinical Pharmacology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden

5Department of Endocrinology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden

6Department of Psychology, University of Gothenburg, Gothenburg, Sweden